Turf Toe

Turf toe gets no respect. Let's take a closer look at the
causes of turf toe and see how to treat it more effectively.

Turf toe is actually a form of hallux limitus. Hallux limitus is
classically described as pain and progressive decrease in the
range of motion of the first metatarsal phalangeal joint (MPJ).
The onset of hallux limitus is due to the following:

Functional hallux limitus - biomechanical function that results
in metatarsus primus elevatus and subsequent repetitive jamming
of the first MPJ.

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Direct physical injury - injury to the articular cartilage or
subchondral bone. These injuries may be due impaction injuries
or hyperextension/flexion of the first MPJ.

But before we go any further, we need to understand that the
terms turf toe and hallux limitus aren't really synonymous. The
fundamental difference between the two terms is the patient
population that they affect. Turf toe is a term used in athletic
circles referring to any injury of the great toe joint.
Consequently, discussions about turf toe will focus on the first
two causes of hallux limitus mentioned above; functional hallux
limitus and direct physical injury. On the other hand, when we
discuss hallux limitus, we're actually referring to a broader,
'non-athletic' patient population and need to include all three
causes of hallux limitus.

Think of turf toe (hallux limitus) as an isolated case of
osteoarthritis limited to the first MPJ. Whether the injury is
acute or due to repetitive loading, the result is a load that is
applied to the subchondral bone that is greater than what the
bone can tolerate. As the injury progresses, a series of micro
fractures will develop in the subchondral bone. The typical soft
spongy character of the metaphyseal bone changes to become
brittle and hard. The result is that the articular cartilage
looses its' underlying support and becomes susceptible to
damage. Juxtachondral eburnation, osteophytes, lipping,
spurring; call them what you like, but what you see on your
x-ray is the slow progressive destruction of the joint.

What's the actual physical change that takes place in the joint
with turf toe? As an easy analogy, consider the changes that
takes place when an apple falls from a height and is damaged.
The skin of the apple appears intact but the underlying pulp is
damaged. In the case of turf toe (hallux limitus), think of the
skin of the apple as the cartilage of the joint and the damaged
pulp of the apple is the subchondral bone. Mild cases of turf
toe (hallux limitus), result in little damage to the subchondral
bone and will merely exhibit signs of inflammatory change within
the joint. Most authors would refer to these cases as stage one
turf toe (hallux limitus). More severe cases result in damage to
the joint surface, the subchondral bone or both. These are the
stage two and three cases of turf toe (hallux limitus) that show
visible change on x-ray. As the subchondral bone becomes
increasingly damaged, it will create an uneven supporting
surface for the cartilage. An increase in activity results in
uneven loading of the joint due to the compression injury of the
subchondral bone.

Is the onset of turf toe always the same? Turf toe that is the
result of functional hallux limitus is going to be insidious in
onset. Functional hallux limitus will usually be seen in younger
athletes as they attempt to increase their activity. It may not
occur during the first athletic season, or the second, but when
it does begin to cause pain, the onset will be more frequent and
more severe, varying with activity. This profile of onset is
simply due to the fact that the athlete is recreating the injury
with every step.

Turf toe caused by a direct injury to the joint may or may not
be obvious. Athletes may not remember an incident of pain since
they're often distracted by the event or game in which they're
involved. The onset of direct injury to the joint may be abrupt,
but also may be insidious becoming increasingly more painful as
the season progresses. The joint pain will subside with rest
only to recur with increased activity. It's not unusual to see
symptoms of turf toe resolve in the off season only to recur
with renewed exercise.

Treatment of turf toe varies with the type of healthcare
provider and includes the use of rest, shoe modifications,
orthotics, steroid injections and surgery. The success of
non-surgical care will vary with the degree of injury, the rate
at which the injury is healing and how much osteoarthritis has
occurred. We see varying degrees of success with orthotics that
promote plantarflexion of the first ray, effectively treating
metatarsus primus elevatus and peroneus longus dysfunction.
Simple arch supports can make a significant difference in the
symptoms of turf toe. Should our patient not respond to
conservative care in a reasonable time period, we are not
reluctant to suggest surgical revision to address the problem
whether it be revisions of the joint defect, shortening of a
long first metatarsal or structural revision of metatarsus
primus elevatus. As mentioned before, the clinical appearance of
dorsal lipping or visible radiographic changes are suggestive of
moderately advanced osteoarthritis, a condition that is only
repaired by joint revision or replacement.

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When treating turf toe be sure to recognize the fact that there
is no nerve innervation in articular cartilage. Pain associated
with stage one turf toe (hallux limitus) is either synovial pain
or bone pain. If we recognize that painful stage one turf toe
(hallux limitus) may be due to bone pain, we then realize that
turf toe should be treated aggressively to insure the long term
viability of the joint.

Nomenclature:

First MPJ - the big toe joint Metatarsus primus elevatus - a
functional or structural position of the first metatarsal First
metatarsal - the foot bone making up the proximal portion of the
big toe joint Hallux - the great toe

Anatomy:

The great toe joint, or first metatarsal joint consists of two
bones. The proximal bone is the first metatarsal and the distal
is called the proximal phalanx or hallux. These two bone move
against each other in an up and down motion through what we
refer to as the sagital plane. Biomechanics: The motion of the
great toe joint is dependant upon the plantarflexion of the
first metatasal. If the first metatarsal is limitied in its'
ability to plantarflex, the joint will jam resulting in
funtional hallux limitus, which as we know is one of the causes
of turf toe.

Symptoms:

Turf toe that is the result of functional hallux limitus is
going to be insidious in onset. Functional hallux limitus will
usually be seen in younger athletes as they attempt to increase
their activity. It may not occur during the first athletic
season, or the second, but when it does begin to cause pain, the
onset will be more frequent and more severe, varying with
activity. This profile of onset is simply due to the fact that
the athlete is recreating the injury with every step. Turf toe
caused by a direct injury to the joint may or may not be
obvious. Athletes may not remember an incident of pain since
they're often distracted by the event or game in which they're
involved. The onset of direct injury to the joint may be abrupt,
but also may be insidious becoming increasingly more painful as
the season progresses. The joint pain will subside with rest
only to recur with increased activity. It's not unusual to see
symptoms of turf toe resolve in the off season only to recur
with renewed exercise.

About the author:
Jeffrey A. Oster, DPM, C.Ped is a board certified foot and ankle
surgeon. Dr. Oster is also board certified in pedorthics. Dr.
Oster is medical director of Myfootshop.com and is
in active practice in Granville, Ohio.

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